 Hello, and welcome to this edition of Quality of Life. I'm your host, Dave Augustine. Today we're gonna talk about orthopedics, and in particular, the spine. Joining us to talk about the subject is from Lakeshore Orthopedics, Dr. Thomas Sylvester. Dr. Sylvester, welcome to the show. Thank you, thanks for having me. Nice, just to start out with, what is your specialty in orthopedics? My specialty is orthopedic spine surgery. So, although while we're on call for orthopedics, we take care of any musculoskeletal injury, my typical practice is focused on disorders of the spine. Okay, now you're a board certified orthopedic surgeon, correct? Yes. What do you have to do to become board certified as far as your educational background, as I'm sure hours of internship or residency, all that sort of stuff? I started out in college, I got my degree in biology at Yale University, which was four years of college. After that, medical school is another four years, and I completed that at Rosalind Franklin in Chicago. And after the four years of medical school, people specialize. My specialty, orthopedic surgery, is a five year residency program, and I completed that residency program at Loyola University in Maywood, Illinois. After we finish our orthopedic residencies, we have the option of going into orthopedic practice or subspecializing in one of the various subspecialties of orthopedics, whether it be spine or hand or sports, foot and ankle, and that is an extra year of training. So I chose to do a spine surgery fellowship at the University of Utah in Salt Lake City. Okay, so do you just focus on spine surgeries that are referred to you, or do you also see patients and do the analysis first? My practice is both, actually. Typically, we do focus oftentimes on the surgical treatment of spine issues, but the vast majority, thankfully for patients, the vast majority of them that see us in the office don't necessarily need a surgery. Okay, how long have you been with Lakeshore Orthopedics? Been with Lakeshore Orthopedics for a year and a half now. Oh, nice, nice. Regarding the spine, just for our viewers, could you go into what purpose or function does the spine serve for the body? The spine really serves a number of purposes. Number one, it's the basic architecture for our entire body to attach our limbs. So it's the base for our arms and legs, essentially. The spine also, it's not only the bony architecture of the spine as a spine surgeon that we concern ourselves with, it's also the contents of the spine. So the spinal cord and the nerves that travel through and exit the spine. Okay, and that all I'd have to see attaches to the brain so it's all related all together and functions as one almost. Absolutely. Definitely, okay. What are some of the conditions that you come across or experience in your care patients? Sure, the majority of patients, thankfully, that we see for a back pain injury, most of them are strains or sprains. Someone's overdone it, they have pulled a muscle in their low back or in their neck and are having pain from that. That's the vast majority of what spine injuries are. Some of the more debilitating injuries that we'll see are people that have disc herniation. So the cushion that's in between the vertebrae, that's in between the bones of the spine, when that becomes injured and protrudes, it can push on nerves causing pain into the arms or the legs or another part of the body. So that's another common problem. In terms of degenerative injuries, we'll often see types of symptoms that are related more to arthritic-type conditions. So just instead of a traumatic injury, a wear and tear of the spine, just like knees and shoulders and hips can become arthritic over time with use, same thing happens with our spine. Okay, for our viewers again, could you give us kind of a summary or a generalization as far as what is arthritis? Sure, arthritis is really wear and tear when we talk about osteoarthritis or the more typical type of arthritis. And what happens is whether it's in the spine where there's a disc wearing out or some of the small joints in the spine wearing out or whether it's a condition with a knee or an ankle or a hip, it's really the loss of cushioning between the bones so bone spurs can form. There's narrowing of the spaces and that can cause pressure on the nerves in the spine in particular. Okay, what are some of the diseases that can affect the spine nowadays? Well, we do oftentimes consider osteoarthritis or wear and tear, a disease, but more specifically, we will see tumors of the spine so whether people have a tumor or a type of cancer that's begun in the spine or whether it's a lung cancer or breast cancer or prostate cancer that's unfortunately metastasized or moved to the spine, that's a common issue. Discurneations are things we worry about. In aging folks, we worry about the loss of bone density and we'll see compression fractures and all that is unfortunately is the result of osteoporosis, a loss of the firmness of the bone and the bone gives way under pressure. Okay, what about scoliosis? Scoliosis is a fortunately not incredibly common but often enough seen by spine surgeons condition. And scoliosis in the most general terms just means curvature of the spine. So there are many different causes for scoliosis. When we see scoliosis in younger folks, infants or in toddlers, it's often related to a genetic condition or sometimes a neuromuscular condition where the musculoskeletal system isn't forming properly. That's not thankfully seen as often in the adolescent age group. So all of us probably have members of our family or we went to school with someone who had to wear a brace at some time or had surgery. That's typically what we call adolescent just meaning that age group. Idiopathic meaning we don't know the specific cause for it, scoliosis. And we know that there's a genetic component that is involved but we don't have the genetics completely worked out. Those folks thankfully most times don't need surgery and are oftentimes treated well just with observation or with bracing. Unfortunately some kids do need to go on to surgery. And then a third type of scoliosis that we'll see is in the aging population or adult population. And when there's wear and tear on the spine, loss of disk height, the joints in the spine wear out. Degenerative arthritis or degenerative scoliosis is really just a form of arthritis. A curvature occurs in the spine because one side wears out a little faster than the other. Now by curvature of the spine, which way does the curve is that when you see your people like leaning forward with their necks down or does the spine actually go side to side? The spine will, in scoliosis, so in adolescent scoliosis, we know it's mostly a side to side bending but there's also a bit of a rotational component. So sometimes we'll see people that are sent to us because in a school screening, they're asked to bend forward and the school nurse will see or the gym or PE coach will see that the patient has one shoulder blade higher than the other. Well that can be seen in scoliosis because of some of that rotation that causes the ribs to rotate a bit. Oh, how about some people you see where they're hunched over or bent way over and you can't straighten up. It's like you wanna go over and just help them and straighten them up or brace their back to help it up. Absolutely. That can be a number of things. In some folks that is, unfortunately, their posture from weak musculature or a type of injury over the years. The term for a true hunching forward of the spine is kyphosis. And that can be, again, similar to scoliosis, can be seen in a younger age population where it has a genetic component and that's just how the person is growing. It can also be seen in folks that have degenerative conditions of the spine or weakened bone where maybe they have had a compression fracture or multiple fractures and it's caused them to hunch forward because their spine is not able to support their weight. Okay. Can spine conditions develop with leaning forward ever from their work environment or repetitive work? If they're like, let's say at a desk job and they're always leaning forward looking at their desk or their papers or whatever, can that contribute to? It can certainly contribute to symptoms. It often doesn't structurally injure the spine, if that makes sense. So we can see people that have muscle imbalances, type muscles, weakened muscles in the core and in the low back that can lead to symptoms, but oftentimes desk jobs don't necessarily correlate to a specific injury. When we see work injuries, it's usually more of a physical type job. And that's not to say that the other folks with office type jobs don't have pain, but thankfully it doesn't often cause a structural problem. Okay. Now I know with the bones, you have bone marrow. Is there bone marrow in the spine as well? Yes, absolutely. What function does bone marrow perform? Bone marrow really is important in the early years in forming blood cells. So that's one of the main functions. Okay. Now also in the spine, you hear once in a while I'm talking about spinal fluid or whatever, is that the same thing or is spinal fluid something different? Spinal fluid is different. So the architecture of the spine is really a column essentially of bone and disc, bone and disc with the disc being a soft material, cartilage type material. It's almost like a essentially like a cushion and a tennis shoe or a shoe insert. That's exactly right. And it involves or allows for motion and shock absorption. Behind that column is a hollow tube. And that's where in the higher spine in the neck and in the thoracic spine, the rib cage area, that's where the spinal cord runs. And when we get down to the low back, the nerves travel through that same area. So those nerves are contained in a sack that's full of spinal fluid. And that sack goes from the sacrum down near the tailbone all the way up and is continuous with the covering around the brain. So the spinal fluid is the same fluid that's up around the brain. Neat. Dead, I didn't know. You talked about tumors and obviously cancer. You know, and cancer metastasize and everything. And a lot of times it goes to the major organs or the bone structure or the spine. What is that process happening or what is it that how cancer forms in the bones or the spine? Sure. Typically when we do see cancer in the spine, the majority of those cases are metastasis. And all that means is that the cancer cells have moved from somewhere else in the body. Typically what happens is there's a proliferation of those cancer cells in the primary tumor, whether it's lung cancer, breast cancer, prostate cancer. And those get into the bloodstream and travel to the site where they then proliferate again and can cause a secondary tumor. Okay, interesting. So about back pain, what is the common type of back pain that people will have? Common type of back pain that we'll see most people for is sort of an acute back pain injury where they've had, say, they're raking their leaves or doing some yard work or carrying something up from the basement where they've just bent down the wrong way to pick something up or they've overdone it either in athletics or sometimes at their job or around the house. And those are typically the muscular type strains that we've talked about earlier. And those are usually injuries that are fortunately self-limiting. Some of the common over-the-counter medications for pain and anti-inflammatory medications as well as heat and ice stretching, things like that usually take care of those types of situations. So those would be your weekend warrior type situations? Absolutely. Basically, as far as it goes. How does that differ with chronic back pain? Sure. Chronic back pain in the symptoms people have can be very similar to those acute symptoms, but unfortunately they have lasted for months or even years at times for people. And oftentimes those injuries can be something much more structural as opposed to just a muscle strain or a muscle or a ligament or tendinous injury. Oftentimes people with chronic back pain will have the arthritis we talked about or a long-standing disc problem that hasn't been treated. Okay, how about chiropractic care? Does that help with the spine in cases or is it just a kind of a he makes it better but there's still a unmasked issue that's around? Chiropractic care is excellent for a lot of patients and for some patients they unfortunately don't gain the relief they're looking for. But that's with all facets of medicine. That's also with spine surgery. Most folks that I've come across in my office that have worked with a chiropractor have gained excellent relief. Unfortunately, just like spine surgery though there are some things that are difficult to treat with chiropractic care and need a different direction. Sure, I know some people that I know use the inverted hanging devices where you strap your feet and you go on the board and hang upside down. I mean it seems to help some people also with theirs. It's probably the same thing where it's actually stretching out the spine. That's exactly right. The inversion tables essentially really negate the effects of gravity. So it's reversing gravity. So instead of the pressure being from the head down it's really from the feet down and it allows the compressed discs to relax and to gain height again. So some people again they find excellent relief with inversion tables. As I know one friend of mine did that and he used the inversion table because he was scheduled for back surgery to go in and correct it and when he came down for his appointment he saw him walking around and we're not gonna touch you because of what the inverted table did. Absolutely. That was kind of nice. What are some of the other home type remedies that people can do to help support good back? Sure. Proper lifting technique, proper body mechanics, proper posture is very important. Anytime we're leaning over, bending at the waist forward to pick something up off of the floor or off of a low table, probably a bad idea. We're really increasing the strain and the forces on the low back. Some of the things that people can do at home if they've had an injury to try to recover are heat and ice. For initial injuries we usually recommend for 48 to 72 hours people ice the injury to try to cut down on the inflammation. We know after that time some people do quite well with heat. Oftentimes people that have had an injury will be seen by a chiropractor or a physical therapist and be started on a home stretching or exercise regimen. The vast majority of people do gain excellent relief with those modalities. Excuse me, how about some over-the-counter drugs like aspirin, ibuprofen or whatever to help alleviate pain? Absolutely. Things like ibuprofen, naproxen, some of the over-the-counter non-steroidal anti-inflammatory medications are excellent for people that have had these sort of like you alluded to earlier, weekend warrior type injuries. The muscle strains and sprains, it really helps to cut down on the inflammation in the area of the injury. Things like Tylenol while not an anti-inflammatory work well as a pain relief medication and sometimes are used in conjunction with the other medications. So the medications, would they help more with the muscular type strains and not the physically bone type strains or do they help with both? They actually help with both. The anti-inflammatory effects that folks get with the ibuprofen or naproxen, they're often used not only for spine injuries or back pain, but for knee arthritis, shoulder arthritis, other types of injuries as well. And we know that by cutting down on the inflammation they work well as an arthritis type medication as well as an acute injury medication. So if I have a back pain that just won't go away or what type of symptoms should I really look for when it comes to, I have to go see a doctor about this because I just can't take it anymore. Sure, the majority of symptoms that we worry about are things that really are suggesting a more serious injury than just a muscle strain. So pain that won't go away after a few weeks despite some anti-inflammatory medications or Tylenol, a stretching program, heat and ice, any type of weakness into the extremities. So you're trying to get up the stairs and gosh, the leg just isn't under you. Any type of pain radiating into the arms or the legs associated with a back or a neck injury. Persistent pain just in that area we worry as someone had a fractured vertebrae. Any type of bowel or bladder issues or balance issues can be suggestive of worrisome nerve compression or spinal cord compression. I know when I was a kid and I started hunting I fell out of the tree, I was like 20 or 30 feet up and landed on right square in my back. But I had all my heavy clothes on and everything but it was great going down but it wasn't when I hit but you could hear all the branches cracking or whatever and I didn't really notice, yeah I bruised some ribs and everything but I really didn't notice the more chronic pain till I was probably five, six, seven years older. Is that a common case where you could sustain an injury but you really don't feel the effects till later on in life? Absolutely. Traumatic injuries we know do in a lot of folks accelerate that degenerative process even if there hasn't been a fracture or a frank disc herniation with the injury. We do know that oftentimes that disc can be injured or the bone can be injured to the point that the normal aging process or the normal wear and tear process is accelerated by that injury. So unfortunately that's not an uncommon scenario. Okay, when do you feel when surgery is the last resort or versus other types of treatment like physical therapy or whatever when you determine no it's time to do surgery? Sure, really surgery should be the last resort for everyone. When people have tried all of the other options, the chiropractic care, physical therapy, anti-inflammatory medications, sometimes people will undergo injections, different types of spinal injections that are essentially cortisone injections to try to relieve their pain or their symptoms. That's really when surgery becomes an option. More rarely we'll see people with an acute injury like a spine fracture that's unstable or if they have a tumor or something like that that becomes more emergent that's causing weakness or pressure on the spinal cord. Those become emergent surgery type situations. I know my grandma had a surgery on her back where they actually had to go in and make more room for the spinal cord because the spine itself was pinching in which she couldn't even walk, she was in so much pain, chiropractors didn't work. Could you go into, in summary, what really means with that surgery, what's all being done? Absolutely, so when we talked earlier about the column arrangement of the spine, so behind the bone in the disc is that open column where the nerves run or the spinal cord runs up higher and that can become a narrow pipe essentially from bone spurs, from disc bulging, just from wear and tear, quite honestly. And as that area narrows, it puts pressure on the nerves. And when there's pressure on the nerves, people have oftentimes leg symptoms that can be present all the time. It can be present just when they're up walking or standing or in certain positions but really the way to alleviate these symptoms people are having is to open that area up again and to take the pressure off of the nerves. So for those types of surgeries, what we do is go in and open that column up. So it's essentially a plumbing job. We're taking a narrow pipe that's tightened or that's clogged and we're opening it up to take the pressure off of the nerves. Those types of surgeries are typically done through an incision in the back. We go through and take away part of the offending bone and ligaments that are pushing on the nerves without necessarily destabilizing the spine and having to do any type of fusion type surgery. How has technology helped in performing these types of surgeries were before? You never even heard of it. Now they're going in on a regular basis and doing that, cleaning it all out or fusing this together and all of that. How has technology come forward? Absolutely. After the, over the years, all types of surgery have become much safer, both because of surgical technique and because of anesthesia techniques. Specific to spine in the last 10 or 15 years though, there's been a big push towards minimally invasive surgery or less invasive surgery. And it's really doing the same types of surgeries that were done traditionally just through a slightly different technique where there can be a different approach used or different retractors or instruments used to make smaller incisions and to decrease the recovery time for patients, get them out of the hospital and functional much more quickly. So it's really all facets of medicine but in spine surgery particularly in the last 10 or 15 years, the push towards minimally invasive surgery has really improved a lot of people's lives. Nice. What are some of the risk factors that can contribute to back pain? Inactivity or overactivity? And when I see inactivity, being physically fit is quite important. Maintaining a healthy body weight is important. We wanna do enough activity that we're fit but not be so overactive or have such a heavy workload that we're injuring ourselves. We know that smoking has a huge negative impact with regard to spying conditions. The types of soft tissues and the types of material that's in the soft tissues of the discs is similar to the types of soft tissues in our skin. And we know that that type of collagen is broken down by smoking. So that's a huge factor for a lot of people. Posture is a big issue for people which goes towards physical conditioning and strength of the abdominal muscles, the low back muscles. Those are important aspects. If we're not fit around our core, we're really increasing the pressure on our spine and not allowing our musculature to act as sort of a natural girdle. Okay. If I wanted to find out more about the spine and its functions and some of the things that can happen to it, where would I go? Do you have a website or a number that can be called? Yes, we do. Our practice's website is LakeshoreOrthopedics.com and we also have phone numbers for both our offices in Sheboygan here on Taylor and in Manitowoc. Okay. We have a couple of minutes left before we have to wrap. Any final thoughts as far as the spine, the health of it or advice to people on how often they should be checked or when they should be checked? Sure. In terms of how often people should be checked, thankfully there's been a big push in schools over the last 20 to 30 years to do routine scoliosis checks. That has the early detection of scoliosis in younger folks has allowed early treatment with bracing and other techniques and has saved thousands of people from surgeries that they otherwise would have needed with later diagnosis. In terms of the adult population, it's really and truly just making sure that we keep our body weight at a reasonable weight, making sure that we stay active and limber and really just being sensible about the way we lift and perform our daily activities. Okay. Well, Dr. Syvester, I'd like to thank you for appearing on the show and talking about the subject. I find it quite interesting. Great. Well, thank you for having me. I appreciate your time. You bet. This concludes our show on orthopedics and the spinal column. If you care to find out more about this episode or have any other suggestions for episodes that you'd like to see, you can contact us through our website at www.wscsheboygan.com. For Dr. Sylvester, Quality of Life, I'm Dave Augustine. Thank you for watching.